Preservation of LDL Cholesterol Targets for Lipid Lowering in New European Guidance Gets Blessing of Prevention Experts

INNSBRUCK, Austria—European atherosclerosis experts, gathered last week for the European Atherosclerosis Society Congress, threw their support behind the importance of a goal-based approach to LDL lowering, as set out in new cardiovascular prevention guidelines.

After the US guidelines, in 2013, abandoned specific LDL cholesterol targets for patients with elevated levels in favor of a risk-based treatment approach, controversy erupted. The Europeans have consistently held fast to treating to LDL goals, a position reiterated in the latest iteration of guidelines released by the European Society of Cardiology (ESC) last month.

“In Europe, there’s a general feeling that people prefer to be given specific targeted guidance to their particular risk,” writing committee member Ian Graham (Trinity College, Dublin, Ireland), told TCTMD following a session dedicated to the new guidelines at the congress. That sentiment is the “primary reason for the difference” between the US and European strategies,” he said. “I think they both work. I don’t think it’s really a fight.”

Specifically, the European guidelines recommend the following goals for LDL cholesterol:

• Very high risk: < 70 mg/dL or a reduction of at least 50% if the baseline is between 70 and 135 mg/dL
• High risk: < 100 mg/dL or a reduction of at least 50% if the baseline is between 100 and 200 mg/dL
• Low to moderate risk: < 115 mg/dL

Measuring HDL cholesterol and triglycerides can also give physicians adequate goals, but there is not enough evidence to support their use with specific targets, Graham explained.

In another presentation, writing committee member Alberico Catapano, PhD (University of Milano, Italy), admitted that the lipid goals have not changed that much since the last publication of ESC guidelines. “They have worked well, so there is no reason to change things that work,” he said.

In general, Graham said specific guidelines help with drug adherence. “There’s a general preference in Europe, at least expressed among patients, that they would prefer to know their actual components of risk and to address each one accordingly,” he commented, adding that patients tend to be driven by hard numbers.

How patients are categorized into the various risk categories has also been subject to debate, given that risk varies by gender, age, and smoking habits. Published with the guidelines is a “risk age” chart that should help clinicians classify their patients accordingly, Graham said in his presentation, adding that the writing committee “could have argued forever on the cut points. It’s not easy to do, and yet people want categories in the same way they want targets.”

“This is an ongoing debate,” Graham admitted, “so who knows where we’ll be in 3 or 4 years.” But the ultimate challenge, he added, is not deciding whether to use a blanket or targeted approach. Rather, it’s the “need to remind people that [statins] only work if you take them.”

Interventions for the Lowest Risk

The guidelines also now extend lifestyle intervention recommendations to patients across all levels of risk, rather than focusing only on high-risk patients. That’s despite the fact that randomized controlled trials of most diet and exercise interventions have never been done, or can’t feasibly be undertaken, in broad patient groups. “Common sense,” however, justifies the inclusion of such recommendations, as physicians have been doing for a while now, Catapano said.

While the ESC guidelines are intended for physicians, in her presentation Eva Bossano Prescott, MD (University of Copenhagen, Denmark), also called upon governments to tackle lifestyle issues from a higher perch.

Clinicians are “also ambassadors and stakeholders in having something happen at the population level,” she explained, calling upon her colleagues to do things like ask their hospitals to hang signs encouraging use of the stairs or advocate for smoking bans. (Smoking is still legal in many bars and restaurants in various European countries, but the rules are not consistent.

All of this is necessary, Bossano Prescott added, because “clinical prevention is more likely to be successful in an environment that is supportive of a healthy lifestyle.”